Cultural Adaptation in Therapy: Part 2
Welcome back to Part Two of our series on cultural adaptations in therapy. In this blog series, I'll summarize the talks and training I've attended, share my work experiences, and reflect on how these have enhanced my knowledge and skills for working in a culturally sensitive manner.
BABCP Event: Cultural Approaches in CBT
I attended a seminar facilitated by the BABCP on Cultural Approaches in CBT, which I believe applies to any psychological model or theory. The seminar covered the following topics:
The Needs of Racial Minority Communities and Existing Barriers
It was discussed that research supporting CBT as evidence-based often has fewer participants from racial minority backgrounds. Some studies do not state the ethnicity of participants, questioning the generalizability of results to all ethnicities.
Research showed that people identifying as White are more likely to improve or recover after IAPT psychological therapies compared to others.
Mental distress in the East is understood differently compared to the West, with spirituality and religion often playing a more significant role in support.
There is a need for more community collaboration and outreach in places of worship and linking up with religious leaders in clinical work.
Professionals and services may not seem competent or accessible to meet the needs of racial minority people. The following cultural barriers to therapy were discussed:
Mistrust of Service/Practitioner: Due to historical exploitation, such as the Tuskegee Syphilis Study and the Henrietta Lacks case, people from minority backgrounds often do not trust services/practitioners.
Lack of Understanding of Cultural Norms and Values by the Therapist
Fear of Stigmatization: Mental health is still heavily stigmatized in certain cultures (e.g., African culture). Clients may fear invalidation and ostracization for their difficulties.
Language and Terminology: Misunderstandings can arise from language barriers.
The link between racism, poverty, violence, and mental health is not often discussed in therapy. Clinicians need to consider how these factors affect clients daily and their environment. Trust and time are needed for clients to feel comfortable discussing these issues.
Assessment, Formulation, and Therapy Considerations Incorporating Aspects of Identity
During the talk, a case example was discussed, illustrating cultural adaptations at each point of the therapeutic process. Here are the key points:
Cultural Adaptations at Point of Referral:
Consider potential barriers to help.
Make services more accessible.
Understand the client's thoughts and feelings.
Reflect on your own thoughts and feelings, considering similarities and differences with the client and their impact on the therapeutic relationship.
Consider using a social identity map.
Cultural Adaptations in Assessment:
Gather background information from systems, other professionals, and referrers.
Offer the option of an interpreter if the client wishes and explain confidentiality.
Be flexible when contacting the client, considering the timing and frequency of appointments (e.g., avoiding clashes with prayer times or religious events).
Once trust is developed, ask about racism or other barriers to therapy, for example: "Is it okay for me to ask if you experienced racism in that situation?"
Cultural Adaptations in Formulation:
Collaboratively develop a shared formulation with the client, including their belief system in the 5 Ps formulation.
Explore differences between the client's home country and the current country, and how these differences contribute to their mental health condition.
Consider how the client's culture, ethnicity, social context, and identity, and their power in society, play into their current formulation.
Do not challenge or minimize a person's beliefs or viewpoints about their current concerns or experiences.
Cultural Adaptations in Intervention:
Explain concepts using the client's terminology. For example, if a client believes black magic is the cause of their mental health issues, explain how black magic may cause distress but is maintained and worsened by a vicious cycle, then explain the CBT cycle.
Integrate cultural support into therapeutic support, such as linking prayer with routines and self-care. Encourage clients to practice mindfulness and relaxation techniques after or during prayer.
Avoid pathologizing spirituality to prevent disengagement.
Respect for beliefs and values is central to engagement.
Values will include ideas about how one should act in various areas of life.
Short Guide to IAPT: BAME Service User Positive Practice Guide
Use a genogram that includes the migration histories of family members and discuss the degrees of acculturation of different family members to understand BAME service users' perspectives.
Develop community-specific steering groups, involve more people from BAME backgrounds in service user groups, and provide workshops in community settings and places of worship.
Use a recovery-based approach that incorporates the social, community, and spiritual needs of the service user.
Ensure therapy provision is available based on service user needs irrespective of their ethnicity, religion, or refugee status.
How This Information Will Influence My Practice:
Throughout the therapeutic process, I will keep in mind the barriers my clients may face in accessing services. I will take the time to build trust with clients before exploring these barriers. Here are some ways to do this:
Provide consistency in sessions.
Offer extended assessments, taking time to explore information with the client and build rapport.
Give clients time to talk through their concerns about therapy and the service.
I will consider the values and spiritual perspectives of service users throughout treatment, understanding that adaptation is essential on an individual basis—one size does not fit all. I will use supervision to support reflective practice and think about ways to adapt therapy. Utilizing resources or directories of organizations that offer support and advocacy will improve engagement in treatment.
I will also think about the practical side of therapy, such as if a client speaks another language or if English is not their first language, asking if they would like an interpreter, and actively listening to any concerns they may have around this. Additionally, I will remember that the same language can have different dialects, such as Bengali.
Even if there are similarities between me and the clients, I will explore the differences in our situations. Finally, I will consider my role and professional power, understanding that we have a duty of care for all clients. But do not worry, i will be reflecting on this last point in another blog.
Cultural Adaptions: Part 1
I work with diverse clients from various cultural, religious, social, economic and ethnic backgrounds. Due to this, I've been reading articles, attending talks and training around cultural competency, cultural adaptions to therapy and anti-racist practice to ensure better relationships with the clients I work with. This will
Ensure that clients feel respected and cared for throughout their time at the service.
Build a richer formulation of clients' needs and make sure their voices are heard throughout their time at the service.
Ensure that intervention best fits the client's needs, expectations and values.
I am also curious about cultural adaptations from assessment and intervention and how they may differ across different cultures. In this blog series, I will be summarising the talks and training I have attended during my work experience and reflecting on how these have enhanced my knowledge and skill set to work culturally sensitively.
Culturally Sensitive Assessment
This talk discussed how culture shapes mental health issues and the importance of cultural sensitivity in assessments. I was also trained in the Cultural Formulation Interview (CFI), a DSM5 tool traditionally used to ensure mental health diagnoses and interventions are more culturally sensitive. The Key Components of the CFI are below:
Cultural Definition of the Problem
In this section of the CFI, we will be trying to look for the following:
A person's way of understanding the problem.
How an individual frames their current problems to other members of the social network, i.e. families and friends.
Example Questions
People often understand their problems in their way, which may be like or different from how doctors describe the problem. How would you describe your problem?
Sometimes, people describe their problems differently to their family, friends, or community members. How would you describe your problem to them?
Cultural Perceptions of Cause, Context, and Support
In this section of the CFI, we will be trying to look for the following:
What the individual identifies is the cause of their problems.
For example, in some cultures, mental health is the result of bad things that happen in their life, problems with others, a physical illness or a spiritual reason.
The individual's life context focuses on resources, social support, and resilience.
I.e. from co-workers, from participation in religion or spirituality
Example Questions
What do you think are the causes of your problem? Is there any support that improves your situation, such as support from family, friends, or others?
What do others in your family, friends, or community think is causing your problem?
Do any aspects of your background or identity affect your problem?
Cultural Factors Affecting Self-Coping and Past Help-Seeking
In this section of the CFI, we will be trying to look for the following:
How does a person cope with their problem? What was/wasn't helpful? And why?
Either by medical care, mental health treatment, support groups, work-based counselling, folk healing, religious or spiritual counselling, or other forms of traditional or alternative healing
The role of social barriers to help-seeking, access to care, and problems engaging in previous treatment. (basically, what got in the way of them accessing help?)
For example, lack of money, work or family commitments, stigma or discrimination, or lack of services that understand your language or background?
Cultural Factors Affecting Current Help-Seeking
In this section of the CFI, we will be trying to look for the following:
An individual's current perceived needs and expectations of help.
The views of the social network regarding help-seeking.
Example Questions
What kind of help would be most helpful to you with your current problem?
Are there other kinds of help that your family, friends, or other people have suggested would be helpful for you now?
Cultural Factors in the Therapeutic Relationship.
In this section of the CFI, we will be trying to look for the following:
Any possible concerns about the clinician-patient relationship, including perceived racism, language barriers, or cultural differences that may undermine goodwill, communication, or care delivery.
Example Questions
Sometimes, doctors and patients misunderstand each other because they come from different backgrounds or have different expectations.
Have you been concerned about this, and can we do anything to provide you with the care you need?
How will this information influence my practice:
The CFI questions can easily be integrated into any initial assessment. The information from these questions could be used alongside any formulation model (such as the 5P's model) to develop a deeper understanding of a person's current concerns from an individual's and their network's social and cultural perspective. It will allow us to work holistically and identify areas of need.
Lastly, Whilst reading this article, do any reflections or viewpoints come to mind?
Comment your views below.